Investigations

Investigations

Investigations for penile cancer are used to determine the extent to which cancer may be affecting the local area or other parts of the body. These investigations are often referred to as staging investigations and may include some or all of the following:

Fine Needle Aspiration (FNA)

An ultrasound scan can be used to identify any enlarged lymph nodes (see below) around the groin area that may have been affected by possible cancer. A biopsy of these nodes using a surgical needle may be taken. The cells that are obtained will be sent for laboratory analysis to determine if they are cancerous or not. This procedure is performed under a local anaesthetic.

The Lymphatic System and Lymph Nodes

The human body is covered by a special type of drainage system called the lymphatic system. This system is responsible for transporting excess fluid from the organs and tissues of the body in a fluid called lymph. Lymph fluid will contain various types of cells and substances that are no longer needed. The lymph fluid will be transported through the lymphatic drainage system and pass through small nodules or nodes that act as filters. These are responsible for filtering out the unwanted substances. If one lymph node is not able to filter out the unwanted substances then the lymph fluid will move to the next one. Cancerous cells which break off from an organ which has cancer can also travel along this route and become trapped at the lymph nodes where they can then accumulate and infiltrate a different area of the body.

Computerised Tomography (CT Scan)

A CT scan checks for any signs of cancer which may have spread to other areas of the body. The CT scan takes a series of x-rays, which are fed into a computer to build up a three-dimensional picture of the inside of the body and will take from 10 to 30 minutes. Men may be given a drink or injection of a dye that allows particular areas to be seen more clearly. The scan is painless, but it will mean lying still for 10 – 20 minutes. A scan will be requested on a very urgent basis and will usually be performed within a few weeks of the request.

Positron Emission Tomography (PET)

This may be used to find out whether penile cancer has spread beyond the penis or to examine any residual areas of abnormality that remain after treatment to see whether they are scar tissue or whether cancer cells are still present. A PET scan uses low-dose radioactive sugar to measure the activity of cells in different parts of the body. A very small amount of a mildly radioactive substance is injected into a vein, usually in the arm. Areas of cancer which are usually more active than surrounding tissue then show up on the scan. It is not usually used on a routine basis but may be performed after initial treatment.

Magnetic Resonance Imaging (MRI)

This test can be used to provide further information about the extent of cancer which may be affecting the penis or other parts of the body and may be performed during treatment. It creates cross-sectional pictures of the human body. Some people are given an injection of dye into a vein in the arm to improve the image. During the scan men will be asked to lie very still on a couch inside a long chamber for up to an hour. This can be unpleasant if they don’t like enclosed spaces. MRI scanning is also very noisy and men will be given earplugs. The chamber is a very powerful magnet, so before entering the room men should remove any metal belongings.

Sometimes an injection may be given into the penis to cause an erection which may then help provide more detail of the area in the penis affected by cancer.

Dynamic Sentinel lymph node biopsy

This procedure is used to detect cancer cells which may have spread to the nearest lymph nodes to the penis on either side of the groin. It is not a procedure that is available in every part of the UK and men may be referred to a specialist centre for this procedure.

A local anaesthetic will first be applied to several areas of the penis and then a radioactive dye injected. X-rays will be taken of the area to visualise the lymph nodes in the groin. Once the lymph node nearest to the cancer has been identified the area will be marked with a special pen and then a surgical plaster will be applied. This procedure may take several hours.

An operation requiring a general anaesthetic will then be performed usually later on the same day in which a blue dye will be injected into the same areas of the penis as before. The dye will be absorbed by the lymph nodes and a special camera can then be used along with the X-rays from the previous procedure to identify the sentinel lymph nodes. These can then be removed by a small surgical incision. The operation may take around 45 minutes to perform.

Providing that men feel well enough after the operation they will usually be allowed home.

However;

Men will need to have a family member or friend who can make sure they are well for the next 24 hours.

Dressings on the biopsy site can be removed after 48 hours when men should be able to bath or shower normally. They should use a clean towel or gauze dressing to pat dry the area.

There may be small dissolvable stitches at the site of the biopsy and these may take a few weeks to fully dissolve.

Men may experience some bruising or some swelling in the groin area. This is usually due to an accumulation of lymph fluid which will improve as the body heals.

Men should contact their health team if they experience any of the following problems:

Persistent bleeding from the wound.

Uncontrolled pain.

A high temperature and shaking or feeling as if you have a bad cold which could be a sign of infection.

Prolonged swelling, redness or a foul smelling discharge from around your wound site which could indicate localised infection.

Men will be given the results of their biopsy a few weeks later when the need for any further treatment will be discussed.

Staging

Once the results of all of the investigations that have been performed and are available it will be possible to create a clinical picture showing the extent to which cancer has affected the body.

Like many cancers, penile cancer is assessed using several methods. One of the most common is called the TNM system where:

T stands for tumour size.

This can be given a value of 1 – 4 indicating how big the area of cancer is within the penis.

Tis

The cancer has not invaded below the superficial (surface) layer of skin. It has not spread to lymph nodes or distant parts of the body.

Ta

A wart like growth that is superficial and has not spread to any other areas.

T1a

A low-grade cancer has grown just below the superficial layer of skin. It has not spread to lymph nodes or distant parts of the body.

T1b

Higher grade cancer that has affected surrounding tissue and blood vessels but still superficial.

T2

The cancer has grown into blood or lymph vessels and/or into the internal chambers of the penis and/or the urethra.

T3

The cancer has grown no further than the urethra.

T4

The cancer has grown into nearby tissues.

N Stands for lymph nodes (please see information above).

N0

Lymph nodes do not contain cancer cells.

N1

There is a lymph node in the groin which has been affected.

N2

There are lymph nodes on either side of the groin which have been affected.

N3

Lymph nodes in the abdomen have been affected.

M This stands for metastases or spread of cancer to other areas of the body.

M0

There is no evidence that the cancer has spread to other organs.

M1a

The cancer has spread to the lungs or distant lymph nodes furthest away from the penis.

M1b

Organs such as the liver or brain have been affected.

Grading

A grade of cancer can also be given to determine how potentially aggressive the cancerous cells may be.This is identified by how abnormal the cancerous cells look compared to normal healthy cells under a microscope.

G1:

Describes cells that look similar to like normal tissue cells.

G2:

The cells are somewhat different from normal cells.

G3:

Describes tumour cells that look very much like each other but don’t look very much like normal cells.

G4:

The tumour cells barely look like normal cells.

A stage of penile cancer can also be worked out using the information above:

Any further treatment will be based on all of these results and decided by a specialist team called a Multi-Disciplinary Team (MDT); a team of urologists, oncologists (cancer specialists), radiologists (X-ray specialists), pathologists (tissue specialists) and specialist nurses. Based on a review of all these results treatment options will be recommended and relayed to men by their specialist team. Any recommendations will be based on the team’s clinical experience and national guidelines.